forms

keeley****Please read this entire page carefully.

Kindly complete all of the attached forms and email or send via secure fax (516.218.7964) at least 24 hours prior to your first session.  As this is an environmentally-aware practice, you may bring hard copies only if you are unable to email/fax as long as you have made me aware of this prior to your session. Please give yourself at least 30 minutes to complete the intake forms.  Completing intake paperwork prior to the initial visit affords the patient more time to talk and to make more productive use of time during the visit.  All forms are required unless otherwise noted.  I am very sorry, but patients who do not complete the intake paperwork cannot be seen. No exceptions.

Scheduling & Cancellation Policy
New Patient Registration
Consent for Treatment
Privacy Policy
Insurance Correspondence – required for all patients using insurance.  Patients will need to contact their insurance carrier’s behavioral health department to correctly complete this form.  It is not recommended that patients contact the general benefits departments.
Consent for release of liability for emotional support from animals in therapy – required for all patients receiving services in Bay Ridge

Please also complete these screening forms and include them with your intake paperwork. Due to new insurance and diagnostic regulations in New York State, I must ask that all patients complete these. In other words, these are all required.  Just like with intake paperwork, please do your best to complete these electronically.  It is not acceptable to simply send the total scores, as the answers to individual questions bear much more relevance to your initial session and assessment.  Completing the screeners in advance will ensure that we get to talk about what you would like to talk about, rather than topics that are not necessarilly applicable to you.  If there is a particular topic that you find it difficult to discuss in person, the screeners can also be helpful insofar as it alleviates that worry of how to bring up such topics.  While I acknowledge that the screeners can be tedious, they are all evidence-based and can be helpful in terms of forming a much more robust and accurate diagnosis.
PHQ-9 Depression Screening
Mood Disorder Questionnaire 
GAD-7 Anxiety Screening
Healthy Living Questionnaire
C-SSRS Risk Rating Scale
Life Events Checklist
PCL-C Abbreviated PTSD Screening
AUDIT Alcohol Use Screening
Drug Use/Abuse Screening
PRIME Thought Patterns Screening
YFAS Eating Habits Scale